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Recognize the limits

National | Move away from command-and-control and toward humility and hope: An action agenda for an agency many conservatives wish didn't exist

Issue: "How shall we then govern?," Oct. 28, 2000

Conservatives have long distrusted the federal Department of Health and Human Services-and rightly so. HHS has for too long functioned as a hidden base for liberal policy initiatives-the current administration, for example, seems to think a condom in every locker is the very definition of good health and responsible human services. And yet, under fresh leadership, the department could become a force for good-an engine of accomplishment for building an America made up of healthy families, empowered workers, and revitalized communities. But to do so, HHS must radically alter what it says, what it does, and how it goes about proving itself to taxpayers. If the "Personal Responsibility and Work Opportunity" welfare reform law of 1996 (PRWORA) was about re-moralizing work, the department's emphasis on reform under a reauthorization of PRWORA must focus on re-moralizing family. It must vigorously use the bully pulpit to say what may be politically incorrect, but what is undoubtedly right for kids and families: Marriage matters, fathers count, and old-fashioned abstinence is imperative. Without an invigorated civil society, America's "health and well-being," which HHS is charged with promoting, will be endangered. And the foundation of civil society is the intact, two-parent family. But strong words about building healthy families are meaningless without measured actions behind them. Under new leadership, HHS should encourage states to use surplus Temporary Assistance to Needy Families (TANF) funds to support Community Marriage Policies initiatives like those operating in 119 communities across the country. This grassroots strategy mobilizes local houses of worship to work together to create a culture in which marriage is revered as a permanent relationship. Clergy commit themselves to insisting that couples complete premarital counseling and to investing in counseling and other services aimed at saving troubled marriages. The governors of Arkansas and Oklahoma have been courageous enough to admit that a "marital state of emergency" exists in our nation, where over half of marriages end in divorce. This cultural crisis can't be solved by government, but government can at least "do no harm." That's why HHS must vigorously support removing the marriage penalty in the federal tax code and across all means-tested programs. HHS should also lead the way in addressing the marriage crisis by offering incentives to states to craft creative policies that increase the number of kids growing up in two-parent families. The new HHS secretary must also champion passage of the Fathers Count Act of 1999, which calls for $150 million in new funding for community-based and local government initiatives that provide support, training, and economic opportunities for low-income fathers. To further complement this approach, we should restructure our child-support program into two divisions: enforcement and empowerment. The former will not tolerate deadbeat dads, and will provide incentives for states to choose policies that encourage family formation and voluntary child support. The latter will provide practical help and training to low-income dads to enable them to take economic responsibility for their kids and to grow in their ability to provide them emotional support. Such a "Building Healthy Families" initiative would also capitalize on a key lesson learned while exploring welfare reform: namely, that abstinence-based education is leading to fewer teen pregnancies. HHS must encourage and publicize successful community-based abstinence programs like Best Friends and A Promise to Keep, and quadruple funding (to about $200 million annually) for such initiatives. This will bring funding for abstinence programs modestly above the level of funding for contraceptive programs, a correlation that corresponds with an unabashed message to teens that "waiting is cool." The 1996 welfare reforms have succeeded beyond even the hopes of their supporters. Throughout the country, states have been empowered to design innovative "make-work-pay" strategies, and former welfare recipients are enjoying the dignity of a paycheck. Nonetheless, the business of welfare reform is unfinished. Vigorous efforts are required to move families not only off of welfare, but out of poverty. An "Empowering America's Workers" initiative would champion a few key innovations needed to help the working poor help themselves. The central thrust of such an initiative would be on helping the working poor to obtain health insurance. Low-income and minority workers are disproportionately represented in the ranks of America's 44 million uninsured families. This is caused in large part by a fundamental unfairness in America's tax code: the deductibility of employer-based health insurance premiums. This means that the insurance "haves" enjoy health-care coverage and are not taxed on the money they spend on their premiums. The insurance "have nots" enjoy neither benefit. We should eliminate the current system of tax breaks for employer-based health insurance and replace it with a new national system of health-care tax credits for individuals and families. Such reform would move the nation toward a private health-care system based on the principles of patient choice and free-market competition. Under this system, people could choose the health plan that best suits their needs, and they would enjoy this coverage despite changing jobs or employment status. Most importantly, under this system, the number of uninsured Americans will decrease. If Congress will not implement such sweeping reform, then HHS must fight hard to ensure that the uninsured working poor can at least get a refundable tax credit to help them purchase private insurance. And the department must also champion efforts to expand the opportunities for low-income Americans to make tax-free contributions to medical savings accounts. These kinds of reforms are necessary to make America's health-care system more just for the working poor. They are also needed because the current system of employer-based health insurance for the middle class, and government health insurance through Medicare (for the elderly) and Medicaid (for the poor and disabled), simply will collapse when the baby boomers start retiring en masse in 2011. Just as Social Security is not financially sustainable given the graying of America, neither is Medicare. With this crisis looming before us, now is the time for decisive action. Thus, HHS must endorse the recommendation of the National Bipartisan Commission on the Future of Medicare: Transform Medicare from a defined-benefits program to a "premium support" program. Under this approach, a Medicare beneficiary would be guaranteed a fixed amount of financial support to purchase a private health plan. Government employees already enjoy the benefits of this kind of program. Conservatives and liberals alike agree that the Federal Employees Health Benefits Program, which utilizes this approach, is a success. Obviously, Congress and not HHS is the authority for making such reform happen. But HHS must do its part by lobbying for reform, and granting waivers (for example, Medicaid waivers) to states that experiment with reforms that promote patient choice of private plans. Although health care and welfare are the big-ticket items in HHS's budget, the department also oversees a variety of programs aimed at strengthening distressed neighborhoods. Two examples are the Community Services Block Grant ($519 million annually) and Social Services Block Grant ($1.9 billion annually). These programs, combined with TANF, provide considerable resources for states to craft long-term, community-focused anti-poverty efforts. HHS should, under new leadership, lobby hard for Congress to allow states to keep their unspent TANF funds so that these can be invested in such initiatives. In the era of devolution, HHS should concentrate more energy on the goal of revitalizing communities, and attempt to achieve that goal by moving vigorously to increase local residents' input into the design of the initiatives underwritten by these funding streams. Overall, HHS should change its perspective from "command and control" to "humility and hope": humility that recognizes the limits of government action, and hope in the power of civic institutions and responsible citizens to solve social problems. The department must emphasize getting resources into the hands of those best positioned to make good decisions: neighbors who know their neighborhood's assets and needs. The Department of Justice's relatively small "Weed and Seed" program operates on such a community-focused funding strategy, and its success rests largely on it. Crime has declined in neighborhoods because solving it has become a community issue, with local residents involved from the start in designing how grant funds should be spent. New policies at HHS should, therefore, give states incentives to involve local residents in choosing how to spend CSBG and SSBG funds. Moreover, the "charitable choice" guidelines that now regulate the TANF block grant should be expanded to cover these two block grants as well. Charitable choice facilitates collaboration between government and the faith community, by protecting the religious character of faith-based organizations (FBOs) serving the poor while simultaneously guarding the civil liberties of beneficiaries. Now that FBOs can compete for government contracts on equal footing with organizations traditionally engaged in partnership with government, new guidelines are expanding and diversifying the network of effective organizations that can reinvigorate distressed communities. Building healthy families, empowering America's workers, and revitalizing our neighborhoods-these will be themes HHS must adopt. But words aren't enough; the department must be continually proving itself. One way to do so is to develop a "return on investment" strategy that attempts to account for the "social return," defined as a lack of dependence on public assistance, improved earnings and tax payments by workers, and contributions to the local economy. Such a strategy already exists within HHS, though it has been hidden in the basement. HHS must let this measure see the light of day, and make it a banner over all the department does. Just as HHS now invests considerable federal resources in basic medical research to learn what works best for healthy bodies, so too it should invest in research that will help us measure the social impact of our programs. In this way we can learn more and more about what works for healthy communities. Through this emphasis on return on investment, conservatives-even compassionate ones-can encourage a results- oriented subculture at HHS.

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